Nokea
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy?
- A. A padded tongue
- B. An endotracheal tube
- C. An airway
- D. A tracheostomy set
Correct Answer: D
Rationale: A tracheostomy set is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy. Options A, B, and C are less critical in this context.
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The nurse is caring for a client with a history of seizures.
- A. What is the priority action for the nurse during a client’s tonic-clonic seizure?
- B. Restrain the client’s limbs to prevent injury.
- C. Place a padded tongue blade in the client’s mouth.
- D. Turn the client to the side to maintain airway.
- E. Administer lorazepam (Ativan) immediately.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Which of the following nursing measures would be MOST appropriate?
- A. Clean the urinary meatus every other day.
- B. Encourage the client to increase fluid intake.
- C. Empty the drainage bag every 2-4 hours.
- D. Irrigate the Foley catheter every 8 hours.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
- A. Continue to monitor the blood pressure
- B. Ask another nurse to check the blood pressure reading
- C. Elevate the client's legs
- D. Call the physician
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.
An adult has completed an alcohol detoxification program and is being discharged with disulfiram (Antabuse). Which statement that the client makes indicates a need for more teaching?
- A. I have learned my lesson. I won't drink more than two beers.'
- B. I will not use mouthwash while I am taking Antabuse.'
- C. I should take the Antabuse every day.'
- D. If I have to go to the emergency room for any reason, I will tell them I take Antabuse.'
Correct Answer: A
Rationale: Planning to drink alcohol (even minimally) while on disulfiram indicates misunderstanding, as it causes severe reactions with alcohol. Other statements show proper understanding.